Adrenal insufficiency relatively common in adults with HIV, TB
The occurrence of adrenal insufficiency was relatively common in patients infected with HIV or TB and predicted by nonspecific clinical features, including weight loss, myalgia, arthralgia, and abdominal pain.
Adults infected with HIV or tuberculosis (TB) commonly experience adrenal insufficiency, according to a systematic review and meta-analysis published in Open Forum Infectious Diseases.
Adrenal insufficiency is potentially life-threatening and can be difficult to diagnosis in the settings of HIV and TB as its symptoms overlap with those of both conditions. In addition, both HIV and TB infection are associated with increased risk for adrenal insufficiency because of the direct and indirect effects of both diseases on the adrenal glands.
To assess the prevalence, significant clinical features, and predictors of adrenal insufficiency in adult patients infected with HIV or TB, researchers at Uganda Martyrs Hospital Lubaga and Makerere University Kampala in Uganda conducted a systematic review and meta-analysis. They searched publication databases through July 2023 for relevant studies to review and used a random-effects model to evaluate the pooled prevalence of adrenal insufficiency among patients with both conditions.
A total of 47 studies were reviewed, of which 26 (55.3%) included patients with HIV infection and 21 (44.7%) included those with TB infection. In addition, 12 (25.5%) studies included data captured from patients with HIV and TB coinfection.
The pooled study populations comprised 2445 patients with HIV infection and 1599 with TB infection, of whom the mean ages were 36.4 and 36.4 years, 34.6% and 43.7% were women, the mean BMI was 20.1 and 19.6 kg/m2, and the mean basal serum cortisol level was 566.7 and 451.3 nmol/L, respectively. In patients with HIV infection, the mean CD4+ count was 222.6 cells/mm3. The pooled prevalence of HIV and TB coinfection was 63.8% (95% CI, 48.5-79.1).
In most studies (82.6%), patients with adrenal insufficiency were diagnosed via intravenous or intramuscular synthetic adrenocorticotrophic hormone or Synacthen stimulation testing.
Among patients with HIV infection, the pooled prevalence of adrenal insufficiency was 28% (95% CI, 18-38; P <.001; I2=98.9%;). Stratified by region, the highest prevalence was observed in Africa (38%; 95% CI, 10-67; P <.001; I2=98.9%), followed by Asia (29%; 95% CI, 13-45; P <.001; I2=97.9%), South America (26%; 95% CI, 8-44; P <.001; I2=62.3%), North America (21%; 95% CI, 4-47; P <.001; I2=93.1%), and Europe (12%; 95% CI, 3-20; P <.001; I2=79.2%).
Among patients with TB infection, the pooled prevalence of adrenal insufficiency was 33% (95% CI, 22-45; P <.001; I2=97.7%), with the highest prevalence observed in Asia (40%; 95% CI, 21-58; I2=95.9%) and Africa (26%; 95% CI, 12-40; I2=97.6%).
In the setting of HIV and TB coinfection, the prevalence of adrenal insufficiency was 29% (95% CI, 13-46; P <.001; I2=98.8%).
Further analysis was performed to identify predictors of adrenal insufficiency. In patients with HIV infection, significant predictors included cytomegalovirus antigenemia positivity, metabolic derangement, rifampicin use, stage 4 disease, and eosinophilia. In patients with TB infection, significant predictors included loss of libido, lower mean supine and erect diastolic blood pressure, weight loss, arthralgia, and myalgia. Of note, patients with multidrug-resistant TB infection and adrenal insufficiency commonly reported abdominal pain, salt craving, myalgia, and the absence of nausea.
Limitations of this analysis include the predominance of low-quality studies, as only 10 studies had quality ratings of “good” or “very good.”
According to the researchers, “Adrenal insufficiency has an insidious onset and presents with nonspecific and subtle clinical features that overlap with those of TB or HIV, delaying early diagnosis and prompt initiation of optimal therapy.”
References:
Kibirige D, Owarwo N, Kyazze AP, et al. Prevalence, clinical features, and predictors of adrenal insufficiency in adults with tuberculosis or HIV: a systematic review and meta-analysis. Open Forum Infect Dis. Published online February 22, 2024. doi:10.1093/ofid/ofae098
Source: Infectious Disease Advisor
